Admissions & Records
College of the Siskiyous, 800 College Ave., Weed, CA 96094
Phone: (530) 938-5500 - Fax: (530) 938-5367 – Email: firstname.lastname@example.org
Extenuating Circumstance Petition
This petition is to change a letter grade (D, F, RW, or W) to an EW in circumstances where the student was unable to
withdraw by the approved withdraw date. This is a formal request for an exception to or waiver of college procedures.
Extenuating circumstances are verified cases of illness, accident, or other circumstances beyond your control. State your
extenuating circumstances in as much detail and as clearly as possible.
Last Name: First Name: MI:
Date of Birth: Student ID#: S00 or SSN:
COS Email: Phone:
City: State: Zip Code:
Students are required to complete both sides of this form with the appropriate signatures from the Instructor of each
class. Attach evidence to support your request.
Petitions with insufficient information, explanation, and documentation will be denied.
Petition Request for (Semester)
I am requesting a late withdraw from the following courses (after the last day to drop) because:
Illness (Chronic conditions do not qualify under this process)
Other Circumstance beyond student’s control that would make it impossible for the student to drop the course in time.
Please Note that if none of the above apply, you are not eligible for an appeal
Student Explanation: (Print or type)